Evaluating Responsible Gambling Programs in Emerging Gambling Markets

1. Evaluating Responsible Gambling
Programs in Emerging
Gambling Markets
Debi A. LaPlante
Division on Addiction, Cambridge Health
Alliance
Harvard Medical School

2. Acknowledgements
• Division on Addiction Colleagues
– Howard Shaffer, Sarah Nelson, Heather Gray, Matthew
Tom, John Kleschinsky, Alec Conte, Layne Keating
• Division on Addiction Support
– Foundation for Advancing Alcohol Responsibility,
National Institutes of Health (National Institute of
General Medical Services), Indian Health Services,
Commonwealth of Massachusetts DPH and MGC,
DraftKings, & Tung Wah Group of Hospitals

3. Impact of Gambling Disorder
Broader
society
Acquaintances
Family and
friends
Gambler

4. Meaning Well and Doing Good
4

5. Public Health Program Evaluation
“Rigorous monitoring and evaluation, with
mechanisms to avoid bias in the data or misplaced
confidence in program effectiveness, are essential
for both progress and sustainability.”
Dr. Tom Frieden, Director of the CDC
Frieden, T. R. (2014). Six Components Necessary for Effective Public Health Program Implementation.
American Journal of Public Health, 104(1), 17–22.

6. “Honest and transparent assessment of
progress or the lack thereof--even or especially
if temporarily inconvenient or embarrassing
because of lack of progress--is critical to allow
continuous refinement of and improvements in
program strategy and implementation.”
Dr. Tom Frieden, Director of the
CDC
Public Health Program Evaluation Cont.
Frieden, T. R. (2014). Six Components Necessary for Effective Public Health Program Implementation.
American Journal of Public Health, 104(1), 17–22.

7. 7
How Should We Develop
Responsible Gambling Programs
and Practices?

8. The Reno Model: Background
“A strategic framework should guide key
stakeholders to develop socially responsible policies
that are founded on sound empirical evidence
rather than those that emerge solely in response to
anecdotally-based socio-political influences.”
-Blaszczynski, Ladouceur, & Shaffer, 2004
8

9. The Reno Model: Principles & Assumptions
9
Inherent Assumptions
1. Safe levels of gambling are
possible
2. Gambling provides benefits
3. People can suffer
harm from excessive
gambling
4. Social benefits must exceed
costs
5. Abstinence is viable, but not
essential
6. Controlled participation is
an achievable goal
Commit to
Reduce the
Incidence &
Prevalence of
Gambling-related
Harms
Inform & Evaluate
Public Policy
Identify Short and
Long-term
Priorities for
Action
Use Science to
Guide the
Development of
Public & Industry-
based Policy
Monitor &
Evaluate using
Scientific
Methods

10. The Reno Model: Responsible Gambling Strategies
10
Responsible Gambling
Policies & practices
designed to prevent &
reduce potential harms
associated with gambling
•Consumer protection,
community/consumer
awareness/education, and
access to efficacious
treatment
Primary Targets
•Individuals who span
the spectrum of risk
(none to serious
problems), with
attention to preventing
transitions to higher risk
Responsibility
•Ultimate decision to
gamble resides with the
individual, and
represents choice
•Individuals must have
the opportunity to be
informed
• Effective in
reducing the
incidence of harms?
• Reduction leads to
decreases in
prevalence of
harms?
Evaluation

11. The 2004 Reno Model: Roadmap for the Future
• Establish a global body representing interests of all
key elements and stakeholders
• Establish and agree upon definitions, terminology,
and standardized measurements
• Coordinate a program of cooperative research that
permits data sharing
• Develop resources than can advance the
objectives of the spectrum of prevention efforts
11

12. The Reno Model: Principles, Assumptions,
& Ethical Underpinnings
12
Inherent Assumptions
1. Safe levels of gambling are
possible
2. Gambling provides benefits
3. People can suffer harm
from excessive gambling
4. Social benefits must exceed
costs
5. Abstinence is viable, but not
essential
6. Controlled participation is
an achievable goal
Commit to Reduce
the Incidence &
Prevalence of
Gambling-related
Harms
Inform & Evaluate
Public Policy
Identify Short and
Long-term
Priorities for
Action
Use Science to
Guide the
Development of
Public & Industry-
based Policy
Monitor &
Evaluate using
Scientific Methods
Shaffer et al., 2015
Autonomy
Self-rule and the
ability to make one’s
own decisions
Beneficence
Efforts to be
helpful and to
do good
Non-
maleficence
Efforts to avoid
doing harm
Justice
Obligation to act on
the basis of fair
adjudication

13. The Reno Model: Responsible Gambling Strategies
13
Responsible Gambling
Policies & practices
designed to prevent &
reduce potential harms
associated with
gambling
•Consumer protection,
community/consumer
awareness/education, and
access to efficacious
treatment
Primary Targets
•Individuals who span the
spectrum of risk (none to
serious problems), with
attention to preventing
transitions to higher risk
Responsibility
•Ultimate decision to gamble
resides with the individual, and
represents choice
•Individuals must have the
opportunity to be informed
Moral Perspective
•Prohibitionist
•Libertarian
•Restrictivist
• Effective in
reducing the
incidence of harms?
• Reduction leads to
decreases in
prevalence of
harms?
Evaluation
Collins et al., 2015

14. Possible Consequences of
Responsible Gambling Practices
• Decrease gambling-related problems
• Increase gambling-related problems
• Have no effect on gambling-related
problems
• Influence gambling-related problems
indirectly through other factors
– e.g., ironic interest increases

15. Seventh Inning Stretch Binge

16. Reducing Injury (and Bike Riding)
(Carpenter & Stehr, 2010)

17. Divergent Consequences for Gambling
• Maximum Bet Limit
– less expenditure per turn
– longer play
• *Slowing Reel Speed
– play is slowed
– play more aggressively
• Removal of Bill Acceptors
– less expenditure in same length of
time
– less recognition of monetary loss
• *Won-Lost Displays
– better understanding of monetary
impact
– chasing of losses
• *Self-limits
– impulsive play reduced
– players might play to notification,
when they otherwise would stop
• Random Time-Outs
– provide gamblers a chance to assess
– gamblers might increase drinking or
smoking behavior
*Adapted from Bernhard & Preston (2004)

19. How Can We Know About What Responsible
Gambling Programs Work?
• Prospective research following gamblers pre- and
post- harm minimization effort
– Prospective research assessing which behaviors and
activities and gambling opportunities influence
problems versus which reflect their problems,
informing future harm minimization strategies
• Actual gambling behavior & less reliance on self-
report
• Randomized Trials
– Coordination with stakeholders for testing

20. Evaluation Feedback & Reporting Loop
20
Develop and implement
RG program &
monitoring system
Use monitoring system
to evaluate program (1)
safety, (2) effectiveness,
and (3) impact
Summarize findings
Identify areas in need of
improvement
Revise RG program

21. Responsible Gambling: A Synthesis
• Why?
– Responsible Gambling programs are operational around the world
– Scientific evidence related to Responsible Gambling is limited and
methodologically weak
• What?
– Identify the body of work that meet minimal methodological quality
standards
– Identify primary evidence-based RG strategies
• How?
– Comprehensive literature review of peer-reviewed publications
– Use a priori set of inclusion criteria to maximize external validity
21
(Ladouceur et al., 2017)

22. Synthesis Strategy
22
n=2,548
• Excluded n=2,079; relevant to problem gambling, but not responsible gambling
n=469
• Excluded n=364; duplicates across searches, non-empirical studies, literature reviews
n=105
• Excluded n=58; irrelevancy, methodological insufficiency
n=47
• Excluded n=18; failure to meet at least 1 of 3 a priori research attribute criteria
n=29
• Final n; met all inclusion criteria
1. Matched control or
comparison group
2. Repeated measures
3. One or more
measurement scales

23. Synthesis Results
0
2
4
6
8
10
12
RG Studies over Time
23

24. Synthesis Results Cont.
9
8
5
4
3
Number of Publications by Type of RG Strategy
Self-exclusion
Behavioral Characteristics
Setting Limits
RG Features
Staff Training/responses
24

25. Synthesis: Self-exclusion (n=9)
• Self-exclusion is associated with improved psychosocial
functioning and assorted reductions in experiences of
harmful consequences of gambling, at least in the
short term
• 2 studies found that about 50% violate after initial
enrollment
• Distinct gambling behavior characteristics of self-
excluders might be used to develop predictive
algorithms
25

26. Synthesis: Behavioral Characteristics (n=8)
• Individuals who have gambling-related problems
are identifiable by gambling behaviors
• Gambling involvement, playing a diversity of
games, is a strong predictor of problems
• Gambling behavior characteristics might be
useful to predictive algorithms, however, more
research is needed
26

27. Synthesis: Setting Limits (n=5)
• Voluntary limit setting seems to be adopted by
few
• Limit setting might reduce gambling behaviors,
but exceeding limits might be a common
occurrence
• Although studies that identify the characteristics
of limit setters are important, more research on
the impacts of limit setting are needed
27

28. Synthesis: RG Features (n=4)
• Message placement and message type
(graphic/text-based) might influence things like
recall, perceived importance, and short-term
gambling outcomes
• People might favor cash display over clock display
or time-based pre-commitment
• Few people use RG features, but for most, they
do not seem to detract from enjoyment
28

29. Synthesis: Gaming Staff (n=3)
• Imparting new knowledge to employees might
be easier than correcting erroneous beliefs
• Employees are poor judges of gambling-
related problems among customers
• Employees find responding to gambling-
related problems difficult (e.g., awkward,
embarrassing, uncertainty)
29

30. Synthesis: Summary
• Responsible Gambling studies are limited, but
in many ways promising
• RG programming activities might be ahead of
scientific support
• More high quality research studies are
needed, including randomized trials and
longitudinal assessments
30

31. Minimally-required
Responsible Gambling Practices
• Population-based education
• Staff training
• Provision of helpline and treatment info
• Limiting direct marketing to at-risk
• Warning signs
• Restrict underage
• Restrict alcohol sales
• Self-exclusion programs
• Ethical advertising and marketing practices
• Modify structural features that contribute
to excessive gambling
Blaszczynski et al., 2011

32. What Can’t Science Tell Us About
Responsible Gambling Programs?
• Science can tell us the costs and benefits of a given
regulation
• Science can eventually tell us how problem gambling
develops and how regulations might intervene in that
process
• Science *can not* tell us how much weight to give to
individual liberty vs. governmental prevention of harm

33. Challenge to Us
• Gambling creates opportunities to improve and
complicate day-to-day life
– To be aware of the changes gambling might create
– To navigate the changing opportunities safely
– To rely upon evidence-based policies and programs that
minimize unanticipated outcomes

34. THE PLAINRIDGE PARK CASINO
GAMESENSE PROGRAM
Evaluating Responsible Gambling in Massachusetts

35. MA Responsible Gambling Initiatives
Voluntary
Self
Exclusion
Voluntary
gambling
limits
• Voluntary self-exclusion
• Who self-excludes?
• What happens to those who self-exclude over time?
• How can VSE be improved
• Setting voluntary gambling limits
• Do subscribers to Play My Way evidence play patterns different
from non-subscribers?
• Do subscribers to Play My Way evidence different play patterns
after subscribing
• Player education
• What services do GameSense Advisors provide?
• How do patrons perceive these services?
• How does exposure to GameSense relate to RG knowledge &
behavior?

36. Evaluation of RG Information Centers
• RGICs are based on the idea that information will mitigate potential
harms associated with gambling
• Ontario RGICs
– visitors reported being satisfied with the information they received &
rated staff highly
• Montreal RGIC
– RGIC visitors learned more about randomness within slot machine
play compared with control group
– RGIC visitors were not more likely than control group visitors to start
using RG strategies
The Osborne Group, 2007; Boutin et al., 2009

37. GameSense Evaluation History
2015
May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Apr.Mar.
Developed
evaluation tools
with MGC and
MCCG; trained
GSAs to use tools
PPC opened; continued training
and refining evaluation tools; used
preliminary results to improve
protocol
Beginning of
Wave 1
2016

38. 2016
May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Apr.Mar.
Downloaded
Wave 1 data
Delivered
report to MGC
Beginning of
Wave 2
2017
End of
Wave 2
GameSense Evaluation History

39. Checklist
• Purpose: formal, enduring record keeping system
• Division responsible for secondary data analysis
• Interaction Categories

40. Selected Findings:
Checklist

41. • From December 1, 2015 until May 31, 2016…
– GSAs completed 5,659 Checklists, which translates
into about 31 interactions each day.
– GSAs interacted with at least 9,343 visitors, or about
52 visitors each day.
• These are not necessarily unique visitors. If a Plainridge
Park patron had a conversation with a GSA in the morning,
and again in the afternoon, she would be counted twice.
What Services do GSAs Provide?

42. What Services do GSAs Provide?
Simple
71%
Instructive
12%
Demonstration
2%
Exchange
15%
(n = 9,342 visitors)

43. Yes, it started as a
Simple Interaction
78%
Yes, it started as an
Instructive Interaction
2%
Yes, it started as a
Demonstration
Interaction
1%
No
11%
Other/missing
8%
Did This Exchange Interaction Begin as a Different Type?
Exchange Interactions (n = 908)

44. What Services do GSAs Provide?
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Providing information
about responsible
gambling
Providing information
about Play My Way
Providing information
about voluntary self-
exclusion
Enrolling visitors in
voluntary self-exclusion
Referring visitors to
professional treatment
or self-helpMajor Categories of GSA Activities
Proportion of all interactions (N = 5,659)
Proportion of all non-Simple interactions (n
= 1,713)

45. Visitor Characteristics
• GameSense Advisors perceived that…
• 41% of visitors in all 4 interaction types were
“repeat customers”
• 7.5% of Exchange visitors were emotionally
distressed and 0.5% of Exchange visitors were
under the influence of drugs or alcohol

46. Selected Findings:
Visitor Survey

47. Visitor Survey
85% response rate
• Reminder: Visitors in
Exchange interactions
represent 15% of all visitors.
Response Rate =
982 Surveys
1155 Eligible Visitors
X 100%

48. My GameSense Advisor…
0 10 20 30 40 50 60 70 80 90 100
was caring
was helpful
was knowledeable
listened to me
Disagree/strongly disagree Uncertain Agree/strongly agree
(n = 159)

49. Did you have any of these concerns when you began your
conversation with the GameSense Advisor?
n %
I was curious about GameSense. 681 69.3
I wanted to learn more about how gambling works. 383 39.0
I wanted to learn more about strategies to keep gambling fun. 305 31.1
I wanted to learn more about or enroll in the Play Management system. 40 4.1
I wanted information about getting legal or financial help. 17 1.7
I wanted to learn more about or enroll in the voluntary self exclusion. 21 2.1
I wanted help for someone else. 18 1.8
I wanted to get my credit suspended. 7 0.7
I wanted the casino to suspend/reduce its marketing to me. 7 0.7
I wanted help or information about problem gambling. 25 2.5
I didn't have any of these concerns at the start of the conversation. 92 9.4
Visitors could select more than one response or no response. (n = 982)

50. To what extent was your primary question answered or
your primary concern resolved?
(n = 982)
completely
88%
somewhat
4%
not at all
1%
missing
7%

51. Have you ever had any of these problems with your gambling?
• Most visitors (83%) did not endorse any gambling-related problems
– 11% reported 1 problem; 5% two problems; and, 0.6% three problems
n %
I had money problems because of my gambling. 12 7.0
I had problems with friends or family members because of my gambling.
11 6.4
I had problems at work because of my gambling. 3 1.8
I had legal problems because of my gambling. 4 2.3
I had problems with my physical health because of my gambling. 3 1.8
I had problems with my mental health because of my gambling. 1 0.6
I was cheated while gambling. 3 1.8
I had some other kind of problem because of my gambling. 4 2.3
Visitors could select more than one response or no response. (n = 171)

52. As a Result of your Conversation with a
GameSense Advisor, will you…
0 10 20 30 40 50 60
Tell someone about the GameSense Info Center
Visit the GameSense website
Think about my own gambling
Think about someone else's gambling
Talk to someone I know you may have a gambling
problem
Reduce my gambling behaviors
Increase my gambling behavior
Percent endorsing
Visitors could select more than one response or no response. (n = 144)

53. Which Groups of People Might Benefit from Having a
Conversation with a GameSense Advisor?
0 10 20 30 40 50 60 70 80 90 100
Anyone who gambles
People at risk for developing a
gambling problem
People who have a gambling
problem
Percent endorsing
Visitors could select more than one response or no response (n = 171)

54. Visitor Survey Summary
• Most visitors in Exchange interactions reported
that they…
– liked their GSA
– approached GSA out of curiosity rather than in need of
problem gambling help
– felt that their concerns were completely resolved

55. Visitor Survey Summary, cont.
• Most visitors in Exchange interactions reported that
they…
– had not experienced problem gambling consequences
– don’t plan to change their gambling behavior
– don’t endorse GS to be beneficial for those who have a
gambling problem or are at-risk for a gambling problem
• Comments were nearly all positive

56. Conclusions

57. Evaluation Loop Revisited
Develop and implement
RG program &
monitoring system
Use monitoring system
to measure (1) safety,
(2) effectiveness, and
(3) impact
Summarize findings
Identify areas in need of
improvement
Revise RG program
52 visitors per day =
about 0.67%
of daily PPC visitors
Effective in
establishing rapport;
will learn more from
Wave 2
Appears safe for
Exchange visitors
(~15%)

58. Limitations
• Representativeness of Visitor Survey findings
Visitors who have Exchange
interactions
Visitors who interact with
GameSense Advisors
PPC patrons
MA casino
patrons

59. Limitations
• Halo effect
– Visitors might have had generally positive feelings
about the GSAs, which influenced their impressions
of GSAs’ knowledge, helpfulness, etc.
• Some missing/incomplete data
• These findings are only generalizable to the PPC
GameSense services

60. Future Work
• What is the general perception of GameSense among all
PPC patrons?
– SEIGMA patron intercept
• What do Plainridge Park employees think about
GameSense?
– Brief employee survey
• How does exposure to GameSense relate to responsible
gambling knowledge and behavior?
– Wave 2 data collection

61. STOP THE PRESSES!
• Wave 2 completed on February 8, 2017
• Survey assess RG concepts and behaviors such as:
– Use of PlayMyWay, gambling myths, & gambling
knowledge
• Data included:
– 7878 checklists
– 691 completed surveys
• 562 first time survey completers
• 129 repeat survey completers
61

62. RG Impact of GameSense (just a taste)
• PlayMyWay use is related to GameSense use
– Those who reported more than one GSA interaction
were more likely to enroll in PMW
• First time respondents who interacted with GSAs
more were more likely to answers gambling-
related questions accurately (e.g., A slot machine
that has not paid out in a long time is “due” to pay out.)
62

63. RG Impact of GameSense (second helping)
• For the most part, GSA exposure was unrelated to RG
activity
– PMW related to number of GSA interactions among first
time respondents; 8 other strategies were unrelated
– Using win limits related to number of GSA interactions
among repeat respondents; financial loss and time limits
were unrelated
• GSA exposure was unrelated to knowledge of the most
likely outcome of any given slot machine play
• More to come June 2017!
63

64. Parting Thoughts on Responsible Gambling
• Evaluation is a necessary component of
Responsible Gambling program development
– Do no harm
• Few Responsible Gambling approaches have been
evaluated, and potentially none are evaluated
sufficiently
• Cooperation among key stakeholders is possible
to advance evidence-based Responsible Gambling
practice
64

65. Thank you!
debi_laplante@hms.harvard.edu
Main Websites:
www.divisiononaddictions.org
www.basisonline.org
www.thetransparencyproject.org
Specialty Websites:
Your First Step to Change
http://www.basisonline.org/selfhelp_tools.html
Brief Biosocial Gambling Screen
http://divisiononaddictions.org/bbgs_new/